Gout + Pseudogout (CPPD) Flashcards by Caitlin McMullen

What is the primary cause of gout?

Deposition of monosodium urate (MSU) crystals in joints and soft tissues due to hyperuricemia
(high serum uric acid levels)

How well did you know this?

Not at all

Perfectly

What are the main causes of hyperuricemia?

Increased urate production
= high purine diet, alcohol, enzyme defects, myeloproliferative disorders

Reduced urate excretion
= chronic kidney disease, diuretics, hypothyroidism

How well did you know this?

Not at all

Perfectly

What is the most common site for acute gout?

The first metatarsophalangeal (MTP) joint

How well did you know this?

Not at all

Perfectly

What is the typical presentation of acute gout?

(1) Severe
(2) sudden-onset pain
(3) hot swollen joint
(4) commonly affecting the MTP joint, (5) lasting about 10 days
(3 days with treatment)

How well did you know this?

Not at all

Perfectly

How does chronic tophaceous gout present?

(1) Painless white accumulations of uric acid (gouty tophi)
(2) which can occasionally erupt through the skin
(3) often associated with diuretic use

How well did you know this?

Not at all

Perfectly

What is the most sensitive test to diagnose gout during an acute attack?

Aspiration of synovial fluid showing needle-shaped, negative birefringent crystals under polarised microscopy

How well did you know this?

Not at all

Perfectly

What is the first-line treatment for acute gout?

NSAIDs (eg, naproxen), unless contraindicated by renal impairment

How well did you know this?

Not at all

Perfectly

What is the second-line treatment for acute gout?

Colchicine

= especially for patients with heart failure or chronic kidney disease.

How well did you know this?

Not at all

Perfectly

What is the third-line treatment for acute gout?

Steroids

How well did you know this?

Not at all

Perfectly

What is the recommended prophylaxis for gout after an acute attack?

Start 4-6 weeks after the acute attack with allopurinol (or febuxostat if allopurinol is not tolerated) along with NSAID cover to prevent exacerbation

How well did you know this?

Not at all

Perfectly

What are the indications for prophylactic therapy in gout?

Two or more acute attacks despite lifestyle modification
Presence of gouty tophi
Heart failure when unable to stop diuretics

How well did you know this?

Not at all

Perfectly

What is the target serum uric acid level for gout prophylaxis?

300-360 µmol/L, monitored every 4-6 weeks

How well did you know this?

Not at all

Perfectly

What does polarised light microscopy of synovial fluid reveal in gout?

Negatively birefringent, needle-shaped crystals

How well did you know this?

Not at all

Perfectly

What does polarised light microscopy of synovial fluid reveal in pseudogout?

Positively birefringent, rhomboid-shaped crystals

How well did you know this?

Not at all

Perfectly

What is the management of acute gout in renal impairment?

Steriods

How well did you know this?

Not at all

Perfectly

What is podagra?

Gout affecting the great toe MTP

How well did you know this?

Not at all

Perfectly

What joints can be affected in gout?

Ankle, foot, hand, wrist, elbow and knee

How well did you know this?

Not at all

Perfectly

A 62-year-old male presents to his GP with a hot, swollen and painful knee. His past medical history includes diabetes, hypertension and a previous duodenal ulcer. His drug history includes ramipril, amlodipine, metformin and indapamide. His observations are normal.

Given the likely diagnosis, what is the most appropriate initial management and why isn’t it NSAIDS

Colchicine

= patient has previous peptic ulcer

How well did you know this?

Not at all

Perfectly

A patient presents with sudden severe pain, redness, and swelling in the first metatarsophalangeal joint. What investigation would confirm the likely diagnosis?

Synovial fluid analysis

How well did you know this?

Not at all

Perfectly

A 67-year-old male presents to his GP with an acutely painful, hot, red, swollen left 1st metatarsophalangeal (MTP) joint. He had experienced a similar episode 6 months previously.

Given the likely diagnosis, what is the mechanism of the preventative medication he is expected to be prescribed?

Xanthine oxidase inhibitor

How well did you know this?

Not at all

Perfectly

A 70-year-old patient presents with an acutely hot, swollen and painful right wrist. Further examination reveals concurrent hepatomegaly, scarring over the antecubital fossa and pinprick marks over his fingertips.
Given the likely diagnosis, what is the most likely finding on joint aspiration?

Positively birefringent rhomboid-shaped crystals

= pseudogout

How well did you know this?

Not at all

Perfectly

A 65-year-old man presents with sub-acute onset ankle pain and swelling. His past medical history includes hypertension (for which he takes lisinopril, amlodipine and indapamide) mild COPD (for which he takes PRN salbutamol and regular seretide) and G6PD deficiency.

On examination, the skin is red and swollen around the right ankle and exquisitely tender to touch. Observations are normal.

What is the most likely diagnosis?

Gout

How well did you know this?

Not at all

Perfectly

A 68-year-old gentleman presents to his general practitioner with a painful left big toe. He is diagnosed with gout and prescribed a course of 5 days of colchicine along with allopurinol. His other medications include ramipril, bendroflumethiazide, citalopram and aspirin. After starting treatment his pain becomes more severe.

What is the most likely to be the cause of his symptoms worsening and explain why?

Starting allopurinol

= allopurinol is the chronic preventative treatment for gout flares, it should not be started during an acute flare

How well did you know this?

Not at all

Perfectly

Risk factors of pseudogout include what?

osteoarthritis
trauma
hyperparathyroidism
haemochromatosis
electrolyte imbalances

How well did you know this?

Not at all

Perfectly

What is the first-line treatment for acute gout attacks?

NSAIDs (eg, naproxen)

What is the first-line treatment if NSAIDs are contraindicated in acute gout attacks?

Colchicine

What is the first-line treatment for chronic gout attacks?

Allopurinol

Why are NSAIDs added when starting allopurinol for gout treatment?

NSAIDs are added to cover potential gout flare-ups that may occur when allopurinol is first started, as rapid lowering of uric acid levels can trigger an acute attack

A 60-year-old man presents to his GP with worsening painful swelling of his left toe, which is red and hot to the touch. He has a past medical history of IBS, hypertension and angina, for which he takes ramipril, bendroflumethiazide and bisoprolol. He is afebrile and otherwise systemically well. Given the likely diagnosis, what is the most appropriate management?

NSAID

A 67-year-old woman presents to the Emergency Department with a severely swollen right ankle and no history of trauma. She is a type 2 diabetic and mentions there is a family history of rheumatoid arthritis. Observations are normal. On examination, her ankle was red, swollen, and more painful when moving. Joint aspiration was performed, and synovial fluid was sent for microscopy, culture, and sensitivity testing. Which features would be consistent with the most likely diagnosis?

Needle-shaped crystals

What is the second-line preventative treatment for gout when allopurinol is not tolerated and lifestyle measures have failed?

Febuxostat

Well-defined “punched-out” erosions and subchondral sclerosis are features characteristic of what?

Recurrent gout

A 65-year-old male attends his GP surgery with a hot, swollen and painful right ankle that developed overnight. His temperature is 37.9C and his other observations are normal. His ankle is extremely painful to touch. He has a past medical history of hypertension and MI and takes indapamide, ramipril, aspirin and simvastatin. What investigation findings would be supportive of the most likely diagnosis?

Joint fluid aspirate polarised light microscopy shows negatively birefringent needle-shaped crystals

A 58-year-old gentleman presents with excruciating pain in his left toe. Passive movement results in pain and he says it is too painful to have a blanket covering his toe joint. He is a teetotaller and has never had this pain before. He has been having back pain and has been taking NSAIDs regularly as a result, he was discharged 1 week ago following a hospital stay of a few days following a gastric ulcer bleed. On examination, there was evidence of florid synovitis of the joint with extreme tenderness. Given the diagnosis, what is the most common side effect to warn him about regarding the most appropriate treatment for his condition?

Colchicine would be the treatment = side effect is diarrhoea

You are an FY1 in A&E and you are asked to see a 58-year-old gentleman with excruciating pain in his left toe. Passive movement results in pain and he claims it is too painful to have a blanket covering his toe joint. He denies any trauma. He has a known history of chronic kidney disease and is on haemodialysis with an eGFR of 5. The registrar performs a joint aspiration and asks you to start basic management. What is the most appropriate medication to treat this patient with?

Steriods

A 65-year-old patient with a history of chronic tophaceous gout, diabetes mellitus, chronic kidney disease and hypertension presents to the emergency department with painful skin lesions and feeling very unwell for the past 24 hours. On examination, the affected skin appears erythematous and blistered. A few lesions have ruptured and started to peel off. He was started on a new medication last week by his doctor. What medications may have contributed to his symptoms?

Allopurinol = can cause rashes, allergic reactions Stevens-Johnson syndrome

When can allopurinol be started in gout?

1. Recurrent attacks 2. Presence of tophi or renal stone 3. Allpurinol is only started 2-3 weeks after the gout episode has resolved.

When are NSAIDs contraindicated?

warfarin, peptic ulcer disease, heart failure, renal imparemnet

What is the pharmacological management for acute gout?

First line - NSAIDs. Second line - colchicine. Third line - steroids

What needs to be started alongside allopurinol in gout?

NSAID or colchicine cover has to be introduced for 3 months

What is the management of acute gout in a patient with a high risk of gastrointestinal side effects, CKD or heart failure?

Colchicine

A 60-year-old man presents to A&E with a two-day history of severe pain, redness, and swelling in his right big toe. He has a history of chronic kidney disease (eGFR 45 mL/min/1.73m²) and hypertension and takes lisinopril and hydrochlorothiazide. He reports a recent episode of diarrhoea and vomiting, treated with antibiotics two weeks ago, but denies trauma or other recent illnesses. On examination, the affected toe is warm, erythematous, and tender to the touch, with no signs of systemic infection. Laboratory tests show a mildly elevated white blood cell count. Joint aspiration reveals an inflammatory synovial fluid, but there are no organisms present on Gram stain. What is the most appropriate management for this patient?

Colchicine = acute attack

What causes pseudogout?

Deposition of calcium pyrophosphate crystals in joints and soft tissues

What joints are most commonly affected in pseudogout?

wrist, knee

What is the key difference between gout and pseudogout in terms of crystal deposition, and how does this affect the ankles?

Type of crystals deposited: 1. gout involves monosodium urate crystals 2. pseudogout involves calcium pyrophosphate crystals

What is chondrocalcinosis in the context of pseudogout?

(1) Refers to the deposition of calcium pyrophosphate in cartilage and other soft tissues without acute inflammation (2) Often seen in elderly patients

How is pseudogout diagnosed?

Diagnosis is confirmed by synovial fluid aspiration showing (1) calcium pyrophosphate crystals (2) positively birefringent (3) rhomboid in shape

What are the common symptoms of pseudogout?

(1) monoarthritis with a swollen, painful, and warm joint. (2) The knee is the most commonly affected joint

How is gout differentiated from pseudogout microscopically?

1. Negatively bi-refringent crystals are diagnostic of gout 2. Positively bi-refringent ‘rods’ are diagnostic of pseudogout

A 54-year-old gentleman presents with a swollen and painful right shoulder. He is currently being investigated for deranged liver function tests and has recently been diagnosed with type 2 diabetes. The shoulder is tender to touch and warm, and there is a restricted range of movement attributable to the pain. No other joints are involved. His temperature is 36.9°C. X-ray of the right shoulder shows chondrocalcinosis and joint space narrowing. What is the most appropriate management plan?

Needle aspiration of the shoulder joint

A 60-year-old man who is currently being treated in hospital for community-acquired pneumonia develops a swollen, painful right knee. He has a background in haemochromatosis and type 1 diabetes. On further questioning, the patient says he fell a few days ago and wonders whether this could have caused his symptoms. He has a knee x-ray which shows chondrocalcinosis and no fractures. What is the most likely diagnosis?

Pseudogout

How should acute pseudogout be treated and is prophylactic treatment recommended?

Acute pseudogout (1) Needle aspiration to exclude sepsis (2) NSAIDs, colchicine, steroids, and rehydration. Chronic = None

What blood tests are commonly seen in pseudogout?

1. Rise in inflammatory markers 2. High serum iron

What conditions are associated with pseudogout?

(1) hyperparathyroidism (2) hypothyroidism (3) hypophosphataemia (4) haemochromatosis (5) Wilson's disease

What are the joint X-ray findings in pseudogout?

1. Chondrocalcinosis 2. Changes for osteoarthritis (LOSS = Loss of joint space, Osteophytes, Subarticular sclerosis, Subchondral cysts).

A 71-year-old man presents with an erythematous, swollen first metatarsophalangeal joint on the left foot. This is causing him considerable pain and he is having difficulty walking. He has never had any previous similar episodes. His past medical history includes atrial fibrillation and type 2 diabetes mellitus and his current medications are warfarin, metformin and simvastatin. What is the most appropriate treatment for this episode? Why isn't it NSAIDS?

Colchicine = NSAIDs should be avoided in elderly patients taking warfarin due to the risk of a life-threatening gastrointestinal haemorrhage

A 54-year-old man presents to the clinic with an acutely painful and red big toe. He is well in himself and there is no evidence of infection or fever. He has suffered gout for some time and tells you he thinks it has recurred. He is currently taking regular allopurinol. What is the next most appropriate option?

Continue allopurinol and commence colchicine = Allopurinol should be continued during an acute attack in patients presenting with an acute flare of gout who are already established on treatment

A 59-year-old man with a history of gout presents with a swollen and painful first metatarsophalangeal joint. He currently takes allopurinol 400mg od as gout prophylaxis. What should happen to his allopurinol therapy?

Continue allopurinol in the current dose = Patients already prescribed allopurinol should continue to take it at the same dose during acute episodes. This is of course in contrast to the advice that patients should not be started on allopurinol until an acute attack has settled.

A 46-year-old man presents with a 2-day history of a painful, swollen, red big toe. On examination, there is erythema and swelling of the right metatarsophalangeal joint of the right big toe. He can weight bear and is apyrexial. You suspect a diagnosis of gout, prescribe colchicine and order blood tests which he has on the same day. The results come back as: Uric acid 320 umol/L (180 - 480) He returns for review 3 weeks later and his symptoms have resolved but would like to know the exact cause of his symptoms. What would be the most appropriate investigation and explain why?

Repeat serum uric acid = (1) a uric acid level ≥ 360 umol/L is seen as supporting a diagnosis (2) if uric acid level < 360 umol/L during a flare repeat the uric acid level measurement at least 2 weeks after the flare has settled

What drugs are known for exacerbating gout?

Thiazides, related diuretics and Anti-tuberculous treatment with pyrazinamide and ethambutol

A 34-year-old woman presented to A&E 12 hours after running a half marathon with an acutely painful big toe. She denies falling or tripping although she says she felt faint after the race. She denies any stiffness but she says her toe is now too painful to move. She denies any family history of autoimmune conditions and she says she only eats red meat twice a week. She has never had this pain before and on examination, there is severe pain even on light touch. There is soft tissue swelling. The registrar decides to do a joint aspiration and an X-ray. What are the most likely set of features seen on the X-ray?

= Normal joint space, soft tissue swelling The radiographic findings characteristic of gout (punched-out lesions, tophi, and erosions) are seen in the intermediate/late stages of the disease